"The River Styx Runs Upstream" by Dan Simmons (1) first appeared in 1982 as an award-winning short story from Twilight Zone Magazine. The story has continued to grow in both popularity and reputation and is considered a classic work within the Science Fiction genre. Dan Simmons' haunting tale invites us into an "alternative" reality, one quite near to our own, but one in which an "alternative" technique challenges us to reconsider the social, economic, and emotional consequences of the care and treatment of the seriously ill and dying. "The River Styx Runs Upstream" has been used in the Literature and Medicine course at the Stanford University School of Medicine and has proven to be a consistent and powerful catalyst for classroom discussion.

After an epigram concerning love and loss from Ezra Pound's Cantos, the story opens with a tale of love and loss from the narrator's own memories - the death of the narrator's mother when he was only a young child. The narrator, who remains unnamed, invites us to share in his thoughts on the day of his mothers funeral: "I loved my mother very much"; "...the unaccustomed tie was like a noose around my neck." As an eight-year old child, he understands the general concept of death, but he seems to misunderstand the events following death as a mirror of the events preceding death, and so he deludes himself with fantasies of his mothers eventual resurrection from the grave. "They're digging her up now" "Now they're hooking her up to big machines." "Will they pump the blood back into her?" "Do her fingers twitch first? Or do her eyes just slide open like an owl waking up?" "She's being walked around now." We are moved with sympathy for this young child as we share in his daydreams concerning the reversibility of death. But then, slowly and subtly, we awaken to the fact that it is we who are self-deluded, it is we who are the young children in this child's world, new visitors to his reality, so similar to our own, but for one dramatic difference: in this child's world, the dead can indeed be "resurrected."

However, like many extreme, yet currently feasible, life-preserving medical procedures, "resurrection" is costly to initiate, expensive to maintain, and produces only limited success. This child's world is thus not some fanciful utopia, but a fallacious dystopia, in which adult arguments for and against the use of the resurrection procedure seem all too familiar and foreboding. After the funeral, Uncle Will argues forcefully against father's decision to resurrect Mother: "...there's still time. You just can't do this"; "...think of the kids..."; "...think about just the money side of it..." Father, as next-of-kin, holds the final authority over Mother's fate. Father has already made plans to have his wife resurrected, regardless of the social, economic, and emotional consequences to himself and his family "It's already done." "It's done, Will."

Resurrection is a prohibitively expensive medical technology: Father commits twenty-five percent of his current assets and pledges twenty-five percent of his future earnings to the "tithing" which is "...necessary because of the expenses of monthly care..." Such an extreme economic commitment parodies our own escalating premiums for health insurance and exorbitant expenses for advanced hospital care. For instance, the current room rate alone for eight days in an intensive care unit can exceed the yearly median family income (2).

Beyond the financial similarities, the results of the resurrection process also appear hauntingly familiar. The resurrected are shadowy caricatures of severely disabled, chronically ill survivors of our own intensive care units. They can never fully recover and so must be given constant care. When Mother is first returned to Father, she appears to have undergone only a few trivial changes due to her recent resurrection: "...her face was flushed and healthy, almost sunburned." "Her skin wasn't cold. It was just different." "Mother never blinked." But these minor physical alterations belie a much more dramatic mental transformation. Father is told to "...think of it as a stroke..." His wife has lost the bulk of her faculties, particularly her ability to speak and her desire to communicate. She has been reduced to a mute automaton, capable of following simple instructions, but with little volition and initiative of her own. She roams about the house in the dark, waters house plants which have long since died, or sits alone for hours in the basement. She must be told what to wear each morning and must be prevented from wandering off into the shaded woods behind the house. It becomes clear that the "resurrection" procedure is a misnomer. Mother has not been resurrected: she has not been returned to life, she has not regained the health and vitality which she once enjoyed. Her body has indeed been reanimated, but her soul remains trapped in a mindless state, somewhere between life and death, seemingly unable to escape in either direction. Furthermore, the resurrection process allows her to be maintained in the resurrected state indefinitely

The "River Styx Runs Upstream" recreates the classic Faustian narrative. Like Faust's pact with the devil, the narrator's father pays a steep price for negotiating with a higher power, in this story rendered as death-transmogrifying technology.

Through his pact with the resurrectionists, Father (and the reader) is made to see the dangers of manipulating a "natural order" which includes death. By juxtaposing images of "natural" death - a decomposed squirrel with one eye, children suffocated in a discarded refrigerator - with images of Mother's living death, the author deftly underscores the theme that no matter how horrible or unfair death may be, alternative states may be worse.

Families of patients in intensive care units (or irreversibly damaged "graduates" of such units can suffer great social and emotional strife, which can far exceed the obvious economic devastation (3). For example, consider the grief and stress inherent to caring for a previously healthy son, now a ventilator-dependent, severely brain-damaged survivor of a near-drowning accident. Similarly, in the alternative reality of this child's world, tremendous social and emotional turmoil is caused by the stress from Mother's resurrection. The children become alienated from their peers - "No one would play with us" - and the family becomes ostracized from their neighbors - "The Resurrectionist families were discriminated against in those days." Both children get insomnia and the narrator's older brother Simon suffers from a recurring nightmare in which Mother is "grinning at him, not smiling, but grinning real wide... her teeth... filed down to points." Father's performance at work begins to suffer and he becomes an alcoholic - "He would start drinking before dinner and stay in front of the television until really late." Simon convinces his brother to run away from home, but they return defeated by morning. Father then insists upon a family vacation "to the shore for the weekend," during which Simon commits suicide. Father, now overwhelmed, has a nervous breakdown and later quits his job as a professor at the University to become a custodian at the shopping mall. "His hair was almost gone except for a few white strands on the sides, and his eyes were sunken in a lined face." Finally, three days before the narrator's graduation from college, Father commits suicide himself.

The narrator, the young child now grown into a man, thus becomes the sole survivor from his family to live through the ordeal of his mother's resurrection. Unlike his brother and father, he did not seek to escape the consequences of the resurrection procedure; rather, he embraced these consequences, becoming so enamored by the "resurrectionist movement" that he later chooses to become a resurrectionist himself. "My career is more than a job to me - I believe in what I do and I'm good at it." In a final plot irony, much as his father had his mother resurrected over the objections of Uncle Will, who suggested that it was not what she would have wanted, the child protagonist, now a grown man, appears to violate both his father's and his brothers last wishes. Out of "love" for his family, and despite a standard policy against resurrecting suicide victims, the narrator apparently has them preserved eternally. The story ends with the same simple phrasing and naive tone used throughout, which belie the eerie and disturbing import of the final sentences:

The narrator's eventual complicity with the resurrectionists pertains directly to students about to be immersed in the highly regimented and conformist medical culture. Many medical students initially feel uncertain, or even repulsed, when learning technical skills. Procedures which violate the human body evoke strong emotions and symbolize the socially-granted power which comes with the physician's role. However, the student, who eagerly tries to shed these emotions and adopt an insiders point of view, quickly loses the ability to recapture these initial feelings of horror. Working at the resurrectionist steel table becomes routine in the same way that removing a diseased heart prior to transplant becomes commonplace. How do we draw the line between life extending technologies that provide genuine benefit and technological routines which are carried out because we have the capacity to do them (4)? Furthermore, how do we draw the line when such procedures also produce significant financial profits for the practitioners or others in society?

In medicine today, the majority of deaths in the hospital are "negotiated." Ventilators are discontinued, the next round of chemotherapy or antibiotics is withheld, or the patient "decides" to forego resuscitation. The mediated and planned character of hospital death means that individuals, most often family members with intense emotional relationships with the patient, are asked to participate in open and explicit decision making about how and when the patient will die. Indeed, current bioethical practices also require individual patients to make assessments, through the device of an advance medical care directive, of how they would like to die or what, in their view, would be considered a "state worse than death" (5). The assumption is that all medical treatments and procedures leading to these states worse than death could then easily be foregone by direct patient choice, thereby making decision making easier for the family and the physicians. The "River Styx" narrative vividly reveals the limits of such a hyperrational approach to matters as emotionally complex as deciding to allow death to occur. Although the father may not have anticipated the full horror of his wife's "living dead" state, a full disclosure of the details of her life in a resurrected state may not have altered his decision. His "choice" is propelled by love, by an inability to imagine life without her. As this story reveals, rationality may have little to do with end of life choices. Perhaps the most poignant lesson for clinicians is revealed in the child narrator's continued love for his mother following her resurrection. The image of the boy clinging to his "mother," holding her hand and talking to her, fulfills the prophecy of the epigram, "What thou lovest well remains the rest is dross/ What thou lovst well shall not be reft from thee."

"The River Styx Runs Upstream" is a compelling and entertaining masterpiece of short fiction. The author plays multiple eternal themes, such as love, life and death, against various issues of critical importance in medicine: ethical dilemmas inherent in technology, the relationships of seriously ill or severely disabled patients and their families to society in general and to the medical establishment specifically, the economics of life-preserving techniques. Resurrection is a metaphor or extension of current technology which can keep a human being alive virtually indefinitely, but perhaps only in a state of extremely limited recovery and only at a substantial cost. The story explores the ramifications of an alternative medical technique in an alternative universe, wherein a society quite similar to our own must wrestle with the same social, economic, and emotional issues surrounding the care and treatment of the critically ill. As outsiders, we readers are able to perceive moral dilemmas and ironies inherent in the Resurrectionist movement. And, upon finishing the last page of this story, we see more acutely these same issues played out in our own hospitals and homes. Such issues are explored elegantly, subtly, dramatically and cathartically in Dan Simmons' dystopic vision "The River Styx Runs Upstream." The addition of this award-winning science fiction story to the canon of great works in literature and medicine will enhance dialogue and debate concerning these difficult decisions.